Bipolar Disorder in Children and Teens

Topic Overview

What is bipolar disorder?

Bipolar disorder causes mood
swings with extreme ups (mania) and downs (depression). When people with this problem are up, they have brief, intense
outbursts or feel irritable or extremely happy (mania) several
times almost every day. They have a lot of energy and a high activity level.
When they are down, they feel
depressed and sad.

What causes bipolar disorder?

Experts don't fully
understand what causes bipolar disorder.

It seems to run in
families. Your child has a greater risk of having it if a close family member
such as a parent, grandparent, brother, or sister has it. Parents may wonder
what they did to cause their child to have bipolar disorder. But there is
nothing a parent can do to cause or prevent it.

What are the symptoms?

In children and teens, moods quickly change from one extreme to another
without a clear reason. But for a child to have bipolar disorder, these mood changes must be different from the child's usual moods and must happen with other symptoms or changes in behaviour. These distinct periods of time with changes in mood and behaviour are called mood episodes. People with bipolar disorder have manic and depressive mood episodes.

Times of mania (ups) or depression (downs) may be less obvious in children
and teens than in adults.

A manic episode lasts at least a week. It is a period of extremely happy, aggressive, and/or angry mood that occurs with some of the following symptoms. The child or teen may:

Have little need for sleep.

Have high energy
levels.

Have extreme confidence in themselves.

Talk very fast.

Have many thoughts at once.

Seem very distracted and unable to focus.

Touch his or her genitals, use sexual language, and approach
others in a sexual way.

Act inappropriate or are intrusive in social settings.

A depressive episode is a period of sad, low, or cranky mood that occurs with some of the following symptoms. The child or teen may:

If your doctor thinks your child or
teen may have bipolar disorder, he or she may ask questions about your child's
feelings and behaviour. Your doctor may also give you and your child written
tests to find out how severe the mania or depression is.

The doctor may do
other tests (such as a blood test) to rule out other health problems. He or she
may ask if your family has any history of mental illness or problems with drugs
or alcohol. Any of these problems can be linked to bipolar disorder.

Why is early diagnosis of bipolar disorder important?

Children with this disorder are more likely to have other problems. These
include
alcohol and drug use problems, trouble in school, running
away from home, fighting, and even suicide. Treating the disorder as early as
possible may keep your child from having these problems.

Watch for
the warning signs of suicide, which change with age.
Warning signs of suicide in children and teens may
include thinking too much about death or suicide. Watch also for things that
can trigger a suicide attempt such as a recent breakup of a relationship or the
loss of a parent or close family member through death or divorce.

How is it treated?

The mood changes that come
with
bipolar disorder can be a challenge. But with the
right treatment, they can be managed well. Treatment usually includes both
medicine (such as mood stabilizers) and
counselling.

An important part of
treatment is making sure your child takes his or her medicine. Children and
teens with this disorder sometimes stop taking their medicines when they feel
better. But without medicine, their symptoms usually come back.

Medicines for bipolar disorder in adults have been well studied. But more
research is being done on how the medicines work and if they are safe
for children and teens.

Keeping a consistent sleep-wake schedule is an important first step in managing bipolar disorder. Set a regular sleep-wake schedule for your child, to make sure they go to bed and wake up the same time every day, even on weekends.

Accepting that your child has bipolar
disorder can be hard. The disorder can be a serious, lifelong problem. Your
child will need long-term treatment and will need to be watched carefully. By
working with your child's doctor, you can find a treatment that works for your
child.

Cause

It seems to run in families. Your child is at greater risk
of having bipolar disorder if a close family member such as a parent,
grandparent, brother, or sister has it.

Stressful or
traumatic events may trigger episodes of
mania or
depression in a child who has bipolar disorder. While it
is normal for such events to cause mood changes, these reactions are much more
extreme for children with bipolar disorder.

Sometimes symptoms of
mania occur as a result of another medical condition, such as an overactive
thyroid gland (hyperthyroidism) or
multiple sclerosis. Symptoms can also develop as a
side effect of some medicines, such as
corticosteroids or antidepressants. Using drugs or
alcohol, consuming too much caffeine, or not getting enough sleep can also
trigger a
manic episode.

Symptoms

Bipolar disorder causes cycles of
mania (or hypomania, a less severe form of mania) and
depression. The different
types of bipolar disorder are based on whether a person has more severe
symptoms of mania or depression.

With bipolar I disorder, moods swing between
mania and depression, sometimes with periods of normal mood between extremes.
All children with this disorder have episodes of mania, but episodes of depression vary. For example, some children do experience depression, and others rarely are depressed.

With bipolar II disorder, depression is
more severe than mania. And manic episodes may last for fewer days and be less
intense.

With cyclothymia, the high and low mood swings are not as severe as the mania and depression seen in bipolar I or bipolar II disorders.

Bipolar, NOS (not otherwise specified), is diagnosed when symptoms of mania and depression are not frequent or severe enough for the above diagnoses.

In children and younger teens, bipolar disorder tends to be rapid-cycling or mixed cycling:

Rapid-cycling means that there have been at least four shifts between depression
and mania over the past 12 months. These shifts occur quickly, sometimes within the same day. Often the shifts happen without a return to a normal mood in between the extremes.

Mixed-cycling (also known as mixed-features) means that
symptoms of both mania and depression occur at the same time.

Following are some common symptoms of bipolar disorder
in children and teens.footnote 1

Depression symptoms

Continuous sad or irritable mood

Loss of interest
in activities that the child enjoyed in the past, such as hobbies, sports, games, or
friends

Significant changes in appetite or body weight (weight loss
or gain)

Sleeping too much or too little or having trouble falling
asleep

Slowed body movements or restlessness

No
energy, or loss of energy

Inappropriate feelings of guilt or
worthlessness

Problems concentrating

Recurrent
thoughts or talk of death or suicide

Headaches, muscle aches, or stomach aches

Manic symptoms

Severe changes in mood from being extremely
irritable to overly silly and elated

Too much energy, such as the
ability to keep going without tiring while the child's peers are
tiring

Decreased need for sleep, such as going for days with very
little sleep and not being tired

Increased obsession with reaching goals or becoming involved in
too many activities

Risky, wild, thrill-seeking behaviour

During severe episodes of mania, your child may suffer
from symptoms of
psychosis, such as having
hallucinations or
delusions of grandeur (for example, telling people
that a rock band is coming to his or her birthday party).

People sometimes
confuse bipolar disorder in children with
other conditions with similar symptoms, such as attention deficit hyperactivity disorder (ADHD).
Although there
is some evidence of a link between ADHD and bipolar disorder, the conditions
have distinct features that you can usually
identify.

In young children, the symptoms of mania are more than just being a bother to adults and other children
now and then. For example, many children can be silly and giggly to a point that it bothers their parents
sometimes. This is not considered to be a sign of mania. But if a child is silly and giggly for several hours,
several times almost every day, and this is interrupting the family's usual routine, then it may be a symptom
of mania.

What Happens

Often the first signs of
bipolar disorder are severe moodiness, unhappiness, or
other
symptoms of depression. It is common for children with
bipolar disorder to be diagnosed first with only
depression and then later to be diagnosed with bipolar
disorder.

A
first manic or hypomanic episode can be triggered by a stressful situation or by certain medicines. Or it may occur without an obvious cause.

Children with bipolar disorder may:

Have trouble getting going in the morning but then have intense energy later in the day.

Miss school often or talk about running away from home.

Become socially isolated and overly sensitive to any kind of rejection or criticism.

Behave irresponsibly, take risks and not think about the consequences, or have trouble making and keeping friends.

Young children

In addition to having manic symptoms, children may have severe, seizure-like
temper tantrums when they are told "no." A child with bipolar disorder may kick, bite,
hit, and make hateful comments, including threats and curses. During tantrums,
which may last for hours, a child may destroy property or become increasingly
violent.

Young children with bipolar disorder
may have more extreme happy or silly moods than most children have.

Teens

Manic behaviour by a teen with bipolar disorder may result in such problems as:

Suspension from school.

Arrest as a result of fighting or drug misuse.

An unwanted pregnancy.

A sexually transmitted infection (STI) from unsafe sexual behaviour.

During depressive episodes, a teen may do poorly in school and may stop taking part in activities he or she enjoyed in the past, such as a sports team.

Watch for warning signs of suicide, which can
include preoccupation with death or suicide or a recent breakup of a
relationship.

Substance use problems are common. Your child's doctor may recommend an evaluation for both
substance use problems and bipolar disorder if your child appears to suffer
from either condition.

Treating other conditions

Sometimes treatment for other conditions can make your
child's bipolar disorder worse. For example:

Treating
depression with antidepressants can trigger a manic
episode or make one worse.

Treatment with
corticosteroids for conditions such as asthma may also trigger a manic or depressive episode.

Medicines that intensify bipolar symptoms may need to be stopped or changed to
a different dose or medicine. Sometimes an additional medicine (such as a mood
stabilizer) can solve the problem. But each child responds to medicines
differently. And it may take several tries before your doctor can identify an
effective medicine, dose, or combination of medicines for your child's
conditions.

What Increases Your Risk

Your child's risk for
bipolar disorder or other mood disorders is higher if
the child:

Has a close relative such as a parent, sibling,
or grandparent with bipolar disorder or another mood disorder.

Has
a family history of problems with alcohol or drugs. Such family members may be using alcohol or drugs as a way to deal with a psychological disorder.

Has had several episodes of major
depression. For every 100 teens with recurring depression, at least 15 are later diagnosed with bipolar disorder.footnote 1

When To Call a Doctor

Your child is thinking seriously of suicide or has recently tried to suicide. Serious signs include these thoughts:

Has decided how to kill himself or herself, such as with a weapon or medicines.

Has set a time and has a plan.

Thinks there is no other way to solve the problem or end the pain.

Your child feels he cannot stop from hurting himself or someone else.

Call a doctor right away if:

Your child hears voices.

Your child has been thinking about death or suicide a lot but does not have a plan for suicide.

Your child is worried a lot that the feelings of depression or thoughts of suicide are not going away.

Seek care soon if:

Your child has symptoms of depression, such as:

Feeling sad or hopeless.

Not enjoying anything.

Having trouble with sleep.

Feeling guilty.

Feeling anxious or worried.

Your child has been treated for depression for more than 3 weeks but is not getting better.

Who to see

Your family doctor, general practitioner, or your child's pediatrician can diagnose and treat bipolar disorder. It is best to build a long-term relationship with
your child's care providers so that when a depressive or manic episode occurs,
the care providers can recognize the changes in the child's behaviour and
provide quick treatment advice.

You
may wish to find a doctor who has special training in children's mental health
conditions or experience treating bipolar disorder in young people.

Your child may also benefit from professional
counselling to help deal with mood changes and the
effects bipolar disorder has on your child's life. A counsellor with special
training in child mood disorders or experience treating child bipolar disorder
may be most helpful. Counselling for bipolar disorder can be provided by
a:

Who to see for family member support

If you are
a family member of a child with bipolar disorder, it is very important to get
the support and help you need. Living with or caring for someone who has
bipolar disorder can be very disruptive to your own life. Manic episodes can be
particularly difficult. It may help to seek your own counsellor or
therapist to support you.

Also, some national support organizations
may have a local chapter in your area or provide information on the Internet.
Examples of such groups include the Canadian Mental Health Association and the Mood Disorders Society of Canada.

Treatment Overview

Mood changes and other
symptoms of bipolar disorder are challenging, but they can be managed
effectively. Treatment usually includes medicines (such as mood stabilizers)
and counselling. Often a combination of both is needed.

Medicine

An important part of treatment is making sure
your child takes his or her bipolar medicine. Often people who feel better after
taking their medicine for a while think they are cured and
no longer need treatment. But when a person stops taking medicine, symptoms
usually return. So it is important that your child follow the treatment
plan.

Counselling

Counselling works best when symptoms of bipolar
disorder are controlled with medicines. For more information on the types of counselling used to treat bipolar disorder, see Other Treatment.

Home treatment

Home treatment includes helping your child get regular exercise, eat a balanced diet, and have a regular sleep schedule. For more information, see Home Treatment.

Hospital treatment

If your child's behaviour is suicidal, aggressive, reckless, or
dangerous, or if he or she is out of touch with reality (psychotic) or
unable to function, the child may need to go into the hospital for a while. Also, many
medicines can make the symptoms of bipolar disorder worse. If your child is
taking one of these, he or she may need to taper off and stop the medicine.
This should only be done under the supervision of a doctor.

Impact on the family

Bipolar disorder has a big impact on both the
child and his or her family. Successful treatment requires that the child and
family members know what happens in bipolar disorder and that the family
members help make sure that the child follows the treatment.

It
can take time for you and your child to accept that the child has a serious,
long-term condition that requires ongoing treatment and constant monitoring.
But keep in mind that by working with your child's doctor, you and your child
can find treatment that works.

Prevention

Bipolar disorder can't be prevented. But there are ways to help manage or
prevent mood changes.

The first and most important preventive
measure is to make sure that your child takes his or her medicines as directed.
Bipolar disorder is a long-term condition and often requires lifelong
treatment with medicines.

Reducing stress, getting regular sleep
and exercise, and staying on a daily routine may help prevent mood swings and
can help with the symptoms of depression and mania.

Home Treatment

Learning as much as you can about bipolar disorder may help you recognize mood changes in your child as they
begin to occur. Catching and treating these mood changes early may help reduce
the length of the manic or depressive episode and improve the quality of your
child's life.

There are steps you can take at home to
reduce your child's symptoms.

Keep your child's room quiet, and have your
child go to bed at the same time every night.

Antidepressants such as selective serotonin reuptake inhibitors (SSRIs), like
fluoxetine (Prozac, for example).

While
antidepressants can be helpful for some children with bipolar disorder, they
can also trigger
mania. Doctors usually prescribe antidepressants along
with mood stabilizers or antipsychotics to help prevent a manic episode. And
the doctor needs to carefully monitor the child for mood changes. Antipsychotics can be used
alone, or they may be combined with mood stabilizers for more effective control
of manic episodes.

Side effects

Medicines for bipolar disorder have side effects that need
to be managed. Some things you cannot change, such as increased urination
(common with lithium). But you can deal with some side effects like weight gain
(common with several medicines used to treat bipolar disorder) by increasing
exercise and reducing calorie intake.

You can work with your child and his or
her doctor to find ways of coping with side effects. If side effects from a
medicine are intolerable, the doctor may have to change the dose or the
medicine.

Advisories

Advisories. Health Canada and the U.S. Food and Drug Administration (FDA) have issued advisories on antidepressant medicines and the risk of suicide. Talk to your doctor about possible side effects and the warning signs of suicide.

Other Treatment

Most children who have
bipolar disorder need medicine. But other forms of
treatment used along with medicine play an important role in balancing mood and
improving quality of life. Counselling, education about the disorder, and stress
reduction can help.

Psychological treatments

Counselling along with medicine has been
used effectively to manage bipolar disorder. Types of therapy that counsellors
use to treat bipolar disorder include:

Interpersonal and social rhythm therapy. This focuses on
social and family relationships and related problems. It teaches family members about the disorder. They learn how to recognize signs of relapse and how to manage what creates stress in each family member. This therapy also helps with setting and keeping a regular social and sleep schedule.

In some cases,
electroconvulsive therapy (ECT) may be an option. In
this procedure, brief electrical stimulation to the brain is given through
electrodes placed on the head. The stimulation produces a short seizure that is
thought to balance brain chemicals.

Complementary therapy

Complementary medicine is
a term used for a wide variety of health care practices that may be used along
with standard medical treatment. A few studies suggest that adding omega-3 fatty acids to medicine (such as lithium) can help reduce the depressive symptoms of bipolar disorder in some people. Omega-3 fatty acids don't seem to have an effect on the manic symptoms of bipolar disorder. And omega-3 fatty acids alone are not a good treatment for bipolar disorder. They are not a replacement for medicine or other therapy used to treat bipolar disorder.footnote 2, footnote 3

Other Places To Get Help

Organizations

Canadian Mental Health Association

www.cmha.ca

Kids Help Phone (Canada)

www.org.kidshelpphone.ca

Provincial and Territorial Helplines and Websites (Canada)

Many of the resources below provide help 24 hours a day, 7 days a week in multiple languages. In an emergency, call 911.

Canada-wide resources

To find a suicide prevention crisis centre phone number or website in your province, visit the Canadian Association for Suicide Prevention's webpage at http://suicideprevention.ca/thinking-about-suicide.

To find a rape crisis or women's centre phone number or website in your province, visit the Canadian Association of Sexual Assault Centres' webpage at www.casac.ca/content/anti-violence-centres.

Kids and teens can call Kids Help Phone at 1-800-668-6868 (toll-free 24/7) or visit http://org.kidshelpphone.ca.

Emergency Social Services. During regular office hours (Monday to Friday, 8 a.m. to 5 p.m.), visit www2.gnb.ca/content/gnb/en/departments/social_development/about_us/emergency_socialservices.html to find the number for the office nearest you. After hours, call 1-800-442-9799 (toll-free).

Family Violence Outreach. Go to www.justice.gov.sk.ca/FVO for a list of community-based organizations and their contact information, or visit www.justice.gov.sk.ca/IVAP.

Child Protection.
Go to www.socialservices.gov.sk.ca/child-protection.pdf for a list of local child protection offices and their contact information, or visit http://www.socialservices.gov.sk.ca/child-protection.

Mental Health and Addictions. Go to www.health.gov.sk.ca/treatment-services-directory for a list of local alcohol and drug treatment services and their contact information, or visit www.health.gov.sk.ca/alcohol-and-drug-services.

Yukon

Provincial Health Information Line. Yukon HealthLine: Call 811 or visit www.hss.gov.yk.ca/811.php. If you are calling from a satellite phone, you can dial 1-604-215-4700 to reach the Health Services Representative at HealthLink BC.

Family and Children's Services. Call 1-867-667-3002 or visit www.hss.gov.yk.ca/family_children.php.

American Academy of Child and Adolescent Psychiatry (2007). Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(1): 107–125. Available online: http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters.

American Academy of Child and Adolescent Psychiatry (2009). Practice parameter on the use of psychotropic medication in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 48(9): 961–973.

National Institute of Mental Health (2008). Bipolar Disorder in Children and Teens. Available online: http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens-easy-to-read/complete-index.shtml.

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